| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
122 |
122 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
112 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$680.00 |
| D1206 |
Topical application of fluoride varnish |
165 |
165 |
$637.50 |
| D0140 |
Limited oral evaluation - problem focused |
60 |
60 |
$515.00 |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
141 |
$356.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$160.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
63 |
$132.00 |